cons

Considering Public Purpose in the Time of COVID-19

In this piece, we will look at the various public purpose considerations as they relate to the development of diagnostics, therapeutics, and vaccines for coronavirus. We explore the foreseeable risks to public safety of loosened regulation, ultimately arguing that even in times of crisis, accountable science and technology development is a choice we can make to protect the public and yield beneficial results, while considering both short- and long-term impacts. 




cons

What Allies Want: Reconsidering Loyalty, Reliability, and Alliance Interdependence

Is indiscriminate loyalty what allies want? The First Taiwan Strait Crisis (1954–55) case suggests that allies do not desire U.S. loyalty in all situations. Instead, they want the United States to be a reliable ally, posing no risk of abandonment or entrapment.




cons

What Allies Want: Reconsidering Loyalty, Reliability, and Alliance Interdependence

Is indiscriminate loyalty what allies want? The First Taiwan Strait Crisis (1954–55) case suggests that allies do not desire U.S. loyalty in all situations. Instead, they want the United States to be a reliable ally, posing no risk of abandonment or entrapment.




cons

Considering Public Purpose in the Time of COVID-19

In this piece, we will look at the various public purpose considerations as they relate to the development of diagnostics, therapeutics, and vaccines for coronavirus. We explore the foreseeable risks to public safety of loosened regulation, ultimately arguing that even in times of crisis, accountable science and technology development is a choice we can make to protect the public and yield beneficial results, while considering both short- and long-term impacts. 




cons

Considering Public Purpose in the Time of COVID-19

In this piece, we will look at the various public purpose considerations as they relate to the development of diagnostics, therapeutics, and vaccines for coronavirus. We explore the foreseeable risks to public safety of loosened regulation, ultimately arguing that even in times of crisis, accountable science and technology development is a choice we can make to protect the public and yield beneficial results, while considering both short- and long-term impacts. 




cons

The Dire Consequences of Trump's Suleimani Decision

Americans would be wise to brace for war with Iran, writes Susan Rice.

"Full-scale conflict is not a certainty, but the probability is higher than at any point in decades. Despite President Trump’s oft-professed desire to avoid war with Iran and withdraw from military entanglements in the Middle East, his decision to order the killing of Maj. Gen. Qassim Suleimani, Iran’s second most important official, as well as Iraqi leaders of an Iranian-backed militia, now locks our two countries in a dangerous escalatory cycle that will likely lead to wider warfare."




cons

What Allies Want: Reconsidering Loyalty, Reliability, and Alliance Interdependence

Is indiscriminate loyalty what allies want? The First Taiwan Strait Crisis (1954–55) case suggests that allies do not desire U.S. loyalty in all situations. Instead, they want the United States to be a reliable ally, posing no risk of abandonment or entrapment.






cons

The Dire Consequences of Trump's Suleimani Decision

Americans would be wise to brace for war with Iran, writes Susan Rice.

"Full-scale conflict is not a certainty, but the probability is higher than at any point in decades. Despite President Trump’s oft-professed desire to avoid war with Iran and withdraw from military entanglements in the Middle East, his decision to order the killing of Maj. Gen. Qassim Suleimani, Iran’s second most important official, as well as Iraqi leaders of an Iranian-backed militia, now locks our two countries in a dangerous escalatory cycle that will likely lead to wider warfare."




cons

What Allies Want: Reconsidering Loyalty, Reliability, and Alliance Interdependence

Is indiscriminate loyalty what allies want? The First Taiwan Strait Crisis (1954–55) case suggests that allies do not desire U.S. loyalty in all situations. Instead, they want the United States to be a reliable ally, posing no risk of abandonment or entrapment.




cons

The Dire Consequences of Trump's Suleimani Decision

Americans would be wise to brace for war with Iran, writes Susan Rice.

"Full-scale conflict is not a certainty, but the probability is higher than at any point in decades. Despite President Trump’s oft-professed desire to avoid war with Iran and withdraw from military entanglements in the Middle East, his decision to order the killing of Maj. Gen. Qassim Suleimani, Iran’s second most important official, as well as Iraqi leaders of an Iranian-backed militia, now locks our two countries in a dangerous escalatory cycle that will likely lead to wider warfare."




cons

What Allies Want: Reconsidering Loyalty, Reliability, and Alliance Interdependence

Is indiscriminate loyalty what allies want? The First Taiwan Strait Crisis (1954–55) case suggests that allies do not desire U.S. loyalty in all situations. Instead, they want the United States to be a reliable ally, posing no risk of abandonment or entrapment.




cons

Who says progressives and conservatives can’t compromise?


Americans often think of our country as being one of great opportunity – where anyone can rise from very modest circumstances, if they work hard and make good choices. We believe that often remains true.

But, for children and youth growing up in poverty, such upward mobility in America is too rare. Indeed, just 30 percent of those growing up in poverty make it to middle class or higher as adults. Though we’ve made progress in reducing poverty over the past several decades, our poverty rates are still too high and our rate of economic advancement for poor children has been stuck for decades. That is an embarrassment for a nation that prides itself on everyone having a shot at the American Dream.

What can we do to reduce poverty and increase economic mobility? In our polarized and poisoned political atmosphere, it is hard to reach consensus on policy efforts. Both progressives and conservatives want lower poverty; but progressives want more public spending programs to improve opportunity and security for the poor, while conservatives generally argue for more responsibility from them before providing more help.

Even so, progressives and conservatives might not be as far apart as these stereotypes suggest. The two of us—one a conservative Republican and the other a progressive Democrat—were recently part of an ideologically balanced group of 15 scholars brought together by the American Enterprise Institute and the Brookings Institution. Our charge was to generate a report with policy proposals to reduce poverty and increase upward mobility. An additional goal was simply to see whether we could arrive at consensus among ourselves, and bridge the ideological divide that has so paralyzed our political leaders.

Together we decided that the most important issues facing poor Americans and their children are family, education and work. We had to listen to each other’s perspectives on these issues, and be open to others’ truths. We also agreed to be mindful of the research evidence on these topics. In the end, we managed to generate a set of policy proposals we all find compelling.

To begin with, the progressives among us had to acknowledge that marriage is a positive family outcome that reduces poverty and raises upward mobility in America. The evidence is clear: stable two-parent families have positive impacts on children’s success, and in America marriage is the strongest predictor of such stability. Therefore marriage should be promoted as the norm in America, along with responsible and delayed child-bearing.

At the same time, the conservatives among us had to acknowledge that investing more resources in the skills and employability of poor adults and children is crucial if we want them to have higher incomes over time. Indeed, stable families are hard to maintain when the parents – including both the custodial mothers and the (often) non-custodial fathers – struggle to maintain employment and earn enough to support their families. Investing in proven, cost-effective, education and training programs such as high-quality preschool and training for jobs in high-growth economic sectors can improve the skills and employability of kids from poor families and lift them out of poverty through work.

Another important compromise was that progressives acknowledged that expecting and even requiring adults on public assistance to work can reduce poverty, as we learned in the 1990s from welfare reform; programs today like Disability Insurance, among others, need reforms to encourage more work. And reforms that encourage innovation and accountability would make our public education programs for the poor more effective at all levels. We need more choice in public K-12 education (through charter schools) and a stronger emphasis on developing and retaining effective teachers, while basing our state subsidies to higher education institutions more heavily on graduation rates, employment, and earnings of their graduates.

Conservatives also had to acknowledge that requiring the poor to work only makes sense when work is available to them. In periods or places with weak labor markets, we might need to create jobs for some by subsidizing their employment in either the private or public sector (as we did during the Great Recession). We agreed that no one should be dropped from the benefit rolls unless they have been offered a suitable work activity and rejected it. And we also need to “make work pay” for those who remain unskilled or can find only low-wage jobs – by expanding the Earned Income Tax Credit (especially for adults without custody of children) and modestly raising the minimum wage.

We also all agreed on other topics. For instance, work-based learning—in the form of paid apprenticeships and other models of high-quality career and technical education—can play an important role in raising both skills and work experience among poor youth and adults.  And, if we raise public spending for the poor, we need to pay for it—and not increase federal deficits. We all agree that reducing certain tax deductions for high-income families and making our retirement programs more progressive are good ways to finance our proposals.

As our report demonstrates, it is possible for progressives and conservatives to bridge their differences and reach compromises to generate a set of policies that will reduce poverty and improve upward mobility. Can Congress and the President do the same?

Editor's Note: this piece first appeared in Inside Sources.

Downloads

Publication: Inside Sources
      
 
 




cons

Honda running 'very conservative' due to higher temps

Honda is running its engines on "very conservative" settings at the first race of the season in Australia for fear of damaging one of its four power units per car




cons

Stefan GP considers US F1 takeover

Serbian businessman Zoran Stefanovic has not abandoned his ambition for his Stefan GP team to race this season, according to a report on Autosport




cons

The Dire Consequences of Trump's Suleimani Decision

Americans would be wise to brace for war with Iran, writes Susan Rice.

"Full-scale conflict is not a certainty, but the probability is higher than at any point in decades. Despite President Trump’s oft-professed desire to avoid war with Iran and withdraw from military entanglements in the Middle East, his decision to order the killing of Maj. Gen. Qassim Suleimani, Iran’s second most important official, as well as Iraqi leaders of an Iranian-backed militia, now locks our two countries in a dangerous escalatory cycle that will likely lead to wider warfare."




cons

What Allies Want: Reconsidering Loyalty, Reliability, and Alliance Interdependence

Is indiscriminate loyalty what allies want? The First Taiwan Strait Crisis (1954–55) case suggests that allies do not desire U.S. loyalty in all situations. Instead, they want the United States to be a reliable ally, posing no risk of abandonment or entrapment.




cons

What Allies Want: Reconsidering Loyalty, Reliability, and Alliance Interdependence

Is indiscriminate loyalty what allies want? The First Taiwan Strait Crisis (1954–55) case suggests that allies do not desire U.S. loyalty in all situations. Instead, they want the United States to be a reliable ally, posing no risk of abandonment or entrapment.




cons

The constraints that bind (or don’t): Integrating gender into economic constraints analyses

Introduction Around the world, the lives of women and girls have improved dramatically over the past 50 years. Life expectancy has increased, fertility rates have fallen, two-thirds of countries have reached gender parity in primary education, and women now make up over half of all university graduates (UNESCO 2019). Yet despite this progress, some elements…

       




cons

Gender and growth: The constraints that bind (or don’t)

At a time when 95 percent of Americans, and much of the world, is in lockdown, the often invisible and underappreciated work that women do all the time—at home, caring for children and families, caring for others (women make up three-quarters of health care workers), and in the classroom (women are the majority of teachers)—is…

       




cons

The Dire Consequences of Trump's Suleimani Decision

Americans would be wise to brace for war with Iran, writes Susan Rice.

"Full-scale conflict is not a certainty, but the probability is higher than at any point in decades. Despite President Trump’s oft-professed desire to avoid war with Iran and withdraw from military entanglements in the Middle East, his decision to order the killing of Maj. Gen. Qassim Suleimani, Iran’s second most important official, as well as Iraqi leaders of an Iranian-backed militia, now locks our two countries in a dangerous escalatory cycle that will likely lead to wider warfare."




cons

What Allies Want: Reconsidering Loyalty, Reliability, and Alliance Interdependence

Is indiscriminate loyalty what allies want? The First Taiwan Strait Crisis (1954–55) case suggests that allies do not desire U.S. loyalty in all situations. Instead, they want the United States to be a reliable ally, posing no risk of abandonment or entrapment.




cons

The Dire Consequences of Trump's Suleimani Decision

Americans would be wise to brace for war with Iran, writes Susan Rice.

"Full-scale conflict is not a certainty, but the probability is higher than at any point in decades. Despite President Trump’s oft-professed desire to avoid war with Iran and withdraw from military entanglements in the Middle East, his decision to order the killing of Maj. Gen. Qassim Suleimani, Iran’s second most important official, as well as Iraqi leaders of an Iranian-backed militia, now locks our two countries in a dangerous escalatory cycle that will likely lead to wider warfare."




cons

What Allies Want: Reconsidering Loyalty, Reliability, and Alliance Interdependence

Is indiscriminate loyalty what allies want? The First Taiwan Strait Crisis (1954–55) case suggests that allies do not desire U.S. loyalty in all situations. Instead, they want the United States to be a reliable ally, posing no risk of abandonment or entrapment.




cons

Button considered 2016 Olympics entry

Jenson Button says he considered trying to compete for Great Britain at the 2016 Olympic Games in the triathlon




cons

Schumacher 'is considered as stable' but still 'critical'

Michael Schumacher's manager says his "condition can be considered as stable" but that he remains in a critical condition




cons

Schumacher shows 'moments of consciousness and awakening'

Michael Schumacher is showing 'moments of consciousness and awakening' after over three months in a coma, according to a statement released by his agent




cons

The Dire Consequences of Trump's Suleimani Decision

Americans would be wise to brace for war with Iran, writes Susan Rice.

"Full-scale conflict is not a certainty, but the probability is higher than at any point in decades. Despite President Trump’s oft-professed desire to avoid war with Iran and withdraw from military entanglements in the Middle East, his decision to order the killing of Maj. Gen. Qassim Suleimani, Iran’s second most important official, as well as Iraqi leaders of an Iranian-backed militia, now locks our two countries in a dangerous escalatory cycle that will likely lead to wider warfare."




cons

What Allies Want: Reconsidering Loyalty, Reliability, and Alliance Interdependence

Is indiscriminate loyalty what allies want? The First Taiwan Strait Crisis (1954–55) case suggests that allies do not desire U.S. loyalty in all situations. Instead, they want the United States to be a reliable ally, posing no risk of abandonment or entrapment.




cons

Hutchins Roundup: Consumer spending, salary history bans, and more.

Studies in this week’s Hutchins Roundup find that consumer spending has fallen sharply because of COVID-19, salary history bans have increased women’s earnings relative to men’s, and more. Want to receive the Hutchins Roundup as an email? Sign up here to get it in your inbox every Thursday. Consumer spending falls sharply because of COVID-19…

       




cons

The dark side of consensus in Tunisia: Lessons from 2015-2019

Executive Summary Since the 2011 revolution, Tunisia has been considered a model for its pursuit of consensus between secular and Islamist forces. While other Arab Spring countries descended into civil war or military dictatorship, Tunisia instead chose dialogue and cooperation, forming a secular-Islamist coalition government in 2011 and approving a constitution by near unanimity in…

       




cons

The View From a Distance: Egypt’s Contentious New Constitution


With violent protests following the second anniversary of the Egyptian revolution, and calls for a new unified government amid dire comments about the stability of Egypt, the world’s attention is again on President Morsi and his country. This follows a tumultuous period last month, when Egyptians went to the polls and ratified a new constitution. The document, criticized as hurried, incomplete, and lacking in consensus is enormously contentious.

In the Saban Center’s newest Middle East Memo, The View From a Distance: Egypt’s Contentious New Constitution, nonresident fellow Mirette F. Mabrouk gives a broad overview of the new constitution, and provides context and analysis for specific sections.

Mabrouk outlines several ways in which, she argues, the document is shaky on the protection of freedoms and rights, particularly those of women, some religious minorities and minors. Mabrouk also encourages analysts to stop viewing this situation as an Islamist/ secular divide, arguing that idea is too simplistic, and lacks the context for greater understanding of Egypt’s domestic politics.

Download » (PDF)

Downloads

Image Source: © Stringer Egypt / Reuters
      
 
 




cons

Consensus plans emerge to tackle long-term care costs


As I’ve noted in a previous JAMA Forum post, there has been a determined and serious effort in recent years by a broad range of organizations and analysts to find a consensus approach to the growing problem of financing long-term care in the United States. These efforts have just resulted in 2 major reports, released in February.

One report comes from the Bipartisan Policy Center (BPC), a national think tank committed to finding workable bipartisan policy solutions. The other is published by the Convergence Center for Policy Resolution, an organization that convenes groups and individuals with conflicting views to seek consensus on difficult issues. Participants in the latter project, known as the Long-Term Care Financing Collaborative, included leaders from major think tanks and philanthropy, insurance associations, health and consumer advocacy groups, organizations representing the interests of older Americans, not-for-profit services, and care for elderly persons, as well as former state and federal officials. (Disclosure: I served as an advisor to the BPC project and as a member of the Collaborative).

It’s a big step forward that the diverse participants in each of these projects were able to come to agreement. Why was that possible?

For one thing, the huge cost of long-term care and earlier failures to agree clearly focused many minds. Future costs are indeed attention-grabbing. Over the next 40 years, for instance, the number of elderly US residents with a severe need for long-term services and supports (LTSS) will increase 140% to more than 15 million. Meanwhile US adults turning 65 today can expect to incur an average of $138 000 in LTSS costs. But there is a wide risk distribution, with 15% of these seniors likely incurring more than $250 000 in expenses. Meanwhile, private insurance that covers the most crippling potential costs is proving harder and harder to find, with insurers increasing premiums and most pulling out of the market—in part because of the heavy and less predictable costs of aging.

Another factor that helped agreement in these projects was that the Urban Institute was able to upgrade its dynamic simulation model and to partner with the actuarial firm Milliman to incorporate claims data into its research to provide far more sophisticated and reliable estimates of several benchmark proposals. Urban made its model available to a range of organizations, including BPC (an employee benefits consulting company), LeadingAge (an association of groups that offer aging-related services), and the Collaborative. The estimates the Urban Institute produced had the effect of narrowing the set of plausible components in any serious plan. For instance, it became clear that a voluntary public catastrophic insurance program—even with subsidies—would be hard-pressed to significantly boost the number of people acquiring insurance protection against catastrophic LTSS costs.

What’s also important about these 2 projects is that the reports agree on several key elements. These elements are likely to form the core of potentially bipartisan legislation under a new Congress and administration. Among the most important are:

  • Improving the market for private insurance. The BPC and the Collaborative proposals call for a number of steps to revitalize the market for private long-term care insurance, such as allowing employment-based retirement savings to be used for premiums and perhaps using autoenrollment to increase the take-up of available coverage. Both plans propose simpler, more standardized plans, with BPC including details of standard options. The Collaborative recommends clearly delineating private and public roles in long-term care insurance, with a stronger public role in addressing high need, long duration risk. As a further step toward bolstering the insurance market, both proposals recommend exploring innovations in long-term care product design. Ideas include possible jointly marketed products with health insurance or Medicare and perhaps long-term care coverage combined with life insurance or annuities.
  • Public catastrophic insurance. Both reports call for a public catastrophic program for individuals with extraordinary costs to protect them from poverty and bankruptcy. In part, this is also to help cover the “tail end” risk that discourages private insurers from offering comprehensive protection, thereby allowing insurers to focus on shorter-term, more predictable coverage.  Each report is cautious about the uncertain cost of such protection but notes that the Medicaid program currently plays the role of insurer of last resort, and so a new catastrophic long-term care insurance program could help shift from the current welfare-based model toward a system of insurance. Echoing this, a new report from LeadingAge, which represents thousands of organizations engaged in aging services, also concluded that a universal program appears the best way to handle catastrophic costs.
  • Retooling Medicaid. Both reports call for revamping Medicaid, by retooling its LTSS component to better serve persons with disabilities and others with long-term needs. Under both the BPC and Collaborative plans, states would offer a sliding-scale “buy-in” for Medicaid’s LTSS benefits. For working individuals with disabilities, this would function as a wraparound service to employer-sponsored health insurance and other health coverage. As both reports point out, the public catastrophic long-term care program would produce some savings for state Medicaid programs, making it financially easier for states to offer the wraparound coverage.
  • Home and community based services. The 2 reports emphasize the importance of fostering community-based care and helping family caregivers.  An AARP report found that approximately 34 million family members and friends—mainly women—provide unpaid care to an older adult each year. The BPC would streamline waivers from federal rules to encourage states to expand home and community services. The Collaborative takes a step further and recommends entirely redefining Medicaid LTSS to include all settings and services currently offered under “mandatory” and “optional” state programs, and by doing so, eliminating the current bias in financing toward institutional care. The BPC suggests exploring some support for these caregivers, including temporary respite care to allow the usual caregiver some time off. The Collaborative published a report last summer, arguing for much greater integration of health and LTSS, including housing and transportation and for greater opportunities for training and support for caregivers.

There is of course a long road between publishing recommendations and the passage of legislation. And there are gaps in these proposals. For instance, how much a full proposal would cost and how it would be paid for (including how much from savings or new taxes) depends on design choices not worked out in detail.

But the similarity of these reports, the range of people and organizations involved and the determination of the participants to find common ground are in stark contrast to the polarization and gridlock we have become accustomed to. It augers well for enacting a solution to the enormous challenge of long-term care costs.


Editor's note: This piece originally appeared in The JAMA Forum

Publication: The JAMA Forum
Image Source: Burazin
      




cons

Health care market consolidations: Impacts on costs, quality and access


Editor's note: On March 16, Paul B. Ginsburg testified before the California Senate Committee on Health on fostering competition in consolidated markets. Download the full testimony here.

Mr. Chairman, Madame Vice Chairman and Members of the Committee, I am honored to be invited to testify before this committee on this very important topic. I am a professor of health policy at the University of Southern California and director of public policy at the USC Schaeffer Center for Health Policy and Economics. I am also a Senior Fellow and the Leonard D. Schaeffer Chair in Health Policy Studies at The Brookings Institution, where I direct the Center for Health Policy. Much of my time is now devoted to leading the new Schaeffer Initiative for Innovation in Health Policy, which is a partnership between USC and the Brookings Institution. I am best known in California for the numerous community site visits over many years that I led in the state while I was president of the Center for Studying Health System Change; most of those studies were funded by the California HealthCare Foundation.

The key points in my testimony today are:

    • Health care markets are becoming more consolidated, causing price increases for purchasers of health services, and this trend will continue for the foreseeable future despite anti-trust enforcement; 
    • Government can still play an effective role in addressing higher prices that come from consolidation by pursuing policies that foster increased competition in health care markets. Many of these policies can be effective even in markets with high degrees of concentration, such as in Northern California.

Consolidation in health care has been increasing for some time and is now quite extensive in many markets. Some of this comes from mergers and acquisitions, but an important part also comes from larger organizations gaining market share from smaller competitors. The degree of consolidation varies by market. In California, most observers believe that metropolitan areas in the northern part of the state have provider markets that are far more consolidated than those in the southern part of the state. Insurer markets tend to be statewide and are less consolidated than those in many other states. The research literature on hospital mergers is now substantial and shows that mergers lead to higher prices, although without any measured impact on quality.[1]

The trend is accelerating for reasons that are apparent. For providers, it is becoming an increasingly challenging environment to be a small hospital or medical practice. There is more pressure on payment rates. New contracting models, such as Accountable Care Organizations (ACOs), tend to require more scale. The system is going through a challenging transition to electronic medical records, which is expensive and requires specialized expertise to avoid pitfalls. Lifestyle choices by younger physicians lead them to pursue employment in large organizations rather than solo ownerships or partnerships in small practices.

The environment is also challenging for small insurers. Multi-state employers prefer to contract with insurers that can serve all of their employees throughout the country. Scale economies are important in building the analytic capabilities that hold so much promise for effectively managing care. Insurer scale is important to make it worthwhile for providers to contract with them under alternative payment models. The implication of these trends is an expectation of increasing consolidation. There is need for both public and private sector initiatives in addition to anti-trust enforcement to foster greater competition on price and quality.

How can competition be fostered? For the insurance market, public exchanges created under the Affordable Care Act (ACA) and private insurance exchanges that serve employers can foster competition among insurers in a number of ways. Exchanges reduce entry barriers by reducing the fixed costs of getting an insurer’s products in front of potential customers. Building a brand is less important when your products will be presented to consumers on an exchange along with information on the benefit design, the actuarial value and the provider network. Exchanges make it easier for consumers to make informed choices across plans. This, in turn, makes the insurance market more competitive. Among public exchanges, Covered California has stood out for making this segment of the insurance market more competitive and helping consumers make choices that are better informed.

The rest of my statement is devoted to fostering competition among providers. I believe that fostering competition among providers is a higher priority because the consequences of lack of competition are potentially larger. In addition, a significant regulatory tool, minimum medical loss ratios, part of the ACA, is now in place and can limit the degree to which purchasers pay too much for health insurance in markets with insufficient competition.

Fostering competition in provider markets involves two prongs—broadened anti-trust policy and other policies to foster market forces. Anti-trust policy, at least at the federal level, to date has not addressed hospital acquisitions of physician practices. These acquisitions lead to higher prices to physicians because hospitals can negotiate higher prices for their employed physicians than the physicians were getting in small practices. Although not yet extensive, a developing research literature is measuring the price impact.[2] Hospital employment of physicians can also be a barrier to physicians steering patients to high-value providers (another hospital or a freestanding provider). To the degree that it reduces the chance of larger physician groups or independent practice associations forming, hospital employment of physicians reduces potential competitors in contracting under alternative payment models.

Another area not addressed by anti-trust policy is cross-market mergers. The concern is that a “must have” hospital in a multi-market system could lead to higher rates for system hospitals elsewhere. Anti-trust enforcement agencies have tended to look at markets separately, so this issue tends not to enter their analyses.

Many have seen price and quality transparency as a tool to foster competition among providers. Clearly, transparency has become a societal value and people increasingly expect more information about organizations that are important to them in both the public and private sector. But transparency is often oversold as a strategy to foster competition in health care provider markets. For one thing, many benefit designs have few incentives to favor providers with lower prices. Copays are the same for all providers and with coinsurance, the insurer covers most of the price difference. Even high deductibles are limited in their incentives because almost all in-patient stays exceed large deductibles and out-of-pocket maximums also come into play for many who are hospitalized. Another issue is that the complexity of comparing prices is a “heavy lift” for many consumers. Insurers and employers now have excellent web tools designed to make it easier for patients to compare prices, but indications are that the tools do not get a lot of use.

Network strategies have the potential to be more effective. The concept behind them is that the insurer is acting as a purchasing agent for enrollees. To the extent that they have the potential to shift volume from high-priced providers to low-priced providers, money can be saved in three distinct ways. The first is the higher proportion of services coming from lower-priced providers. The second is the additional discounts from providers seeking to become part of the limited or preferred network. Finally, if a large enough proportion of patients are enrolled in plans with these incentives, providers will likely increase the priority given to cost containment. In creating networks, insurers are increasingly using broader and more sophisticated measures of price as well as some measures of quality. Cost per patient per year or cost for all services involved in an episode is likely to have more relevance than unit prices. Using such measures to judge providers for networks has strong analytic parallels to reformed payment approaches, such as ACOs and bundled payments for episodes of care. Network strategies also create more opportunities for integration of care. For example, a limited network or a preferred tier in a broader network could be mostly limited to providers affiliated with a large health care system. Indeed, some health systems are developing their own health plan or partnering with an insurer to offer plans that favor their own providers.

In this testimony, I discuss two distinct network strategies. One is the limited network, which includes fewer providers than has been the norm in private insurance. The other is the tiered network, where the network is broad but a subset of providers are included in a preferred tier. Patients pay less in cost sharing when they use the preferred providers. Limited networks are a more powerful tool to obtain lower prices because patient incentives are stronger. If patients opt for a provider not in the limited network, they are subject to higher cost sharing and might have to pay the provider the difference between the charge and what the plan allows. Results of these stronger incentives are seen in a number of studies by McKinsey and Co. that have shown that on the public exchanges, limited network plans have premiums about 15 percent lower than plans with broader networks.

Public and private exchanges are an ideal environment for limited network plans. The fixed contributions or subsidies to purchase coverage mean that consumers’ incentives to choose a plan with a lower premium are not diluted—they save the full difference in premium. Exchanges do not have the “one size fits all” requirement that constrains many employers in using this strategy. If an employer is offering only one or two plans, it is important that an overwhelming majority of employees find the network acceptable. But a limited network on an exchange could appeal to fewer than half of those purchasing on the exchange and still be very successful. In addition, tools provided by exchanges to support consumers facilitate comparisons of plans by having each plan’s network accessible on a single web site.

In contrast, tiered networks have the potential to appeal to a larger consumer audience. Rather than making annual choices of which providers can be accessed in network, tiered networks allow these decisions on a point-of-service basis. So the consumer always has the option to draw on the full network. Considering the greater popularity of PPOs than HMOs and the fact that tiered formularies for prescription drugs are far more popular than closed formularies, the potential market for tiered networks might be much larger. But this has not happened. In many markets, dominant providers have blocked the offering of tiered networks by refusal to contract with insurers that do not place them in the preferred tier. This phenomenon was seen in Massachusetts, where 2010 legislation prohibiting this practice led to rapid growth in insurance products with tiered networks.

Some Californians are familiar with a related approach of reference pricing due to the pioneering work that CalPERS has done in this area for state and local employees. Reference pricing is really an “extra strength” version of the tiered network approach. An insurer sets a reference price and patients using providers that charge more are responsible for the difference (although providers sometimes do not charge patients in such plans any more than the reference price). So the incentive to avoid providers whose price exceeds the reference price is quite strong. While CalPERS has had success with joint replacements and some other procedures, a key question is what proportion of medical spending might be suitable to this approach. For reference pricing to be suitable, the services must be “shoppable,” meaning that they must be discretionary with the patient and can be planned in advance. One analysis estimates that only one third of health spending is “shoppable.”[3]

While network approaches have a lot of potential for fostering competition in health care markets, including those that are consolidated, they face a number of challenges that must be addressed. First, transparency about networks must be improved. Consumers need accurate information on which providers are in a network when they choose plans and when they choose providers for care. Accommodation is needed for patients under treatment if their provider should drop out of a network or be dropped from one. Network adequacy regulations are needed to protect consumers from networks that lack access to some specialties or do not have providers close enough to their residence. They are also important to preclude strategies that create networks unlikely to be attractive to patients with expensive, chronic diseases. But if network adequacy regulation is too aggressive, it risks seriously undermining a very promising tool for cost saving. So regulators must very carefully balance consumer protection with cost containment.

Some consider the problem of “surprise” balance bills, charges by out-of-network providers that patients do not choose, to be more significant in limited networks. This may be the case, but the problem is substantial in broader networks as well, and its policy response should apply throughout private insurance.

Another approach to foster competition in provider markets involves steps to foster independent medical practices. Medicare has taken steps to ease requirements for medical practices to contract as ACOs. It recently took some steps to limit the circumstances in which hospital-employed physicians get higher Medicare rates than those in office-based practice. Private insurers have provided support to some practices to incorporate electronic medical records into their practices. To the degree that independent practice can be made more attractive relative to hospital employment, competition in provider markets is likely to increase.

Additional restrictions on anti-competitive behavior by providers can also foster competition. These behaviors include “all or nothing” contracting requirements in which a hospital system requires insurers to contract with all hospitals in the system and “most favored nation” clauses in which insurers get providers to agree not to establish lower rates for other insurers.

Although the focus of discussion about policy in this testimony has been about fostering competition, regulatory alternatives that substitute for competition should not be ignored. At this time, two states—Maryland and West Virginia—regulate hospital rates. Some states, mostly in the Northeast, have been looking at this approach. Although I respect what some states have accomplished with this approach in the past, I need to point out that the current environment poses additional challenges for rate setting. The notion that rates would be the same for all payers, a longstanding component in Maryland, is unlikely to be practical today because rate differences between private insurance, Medicare and Medicaid are so large. So differences would likely have to be “grandfathered.” More practical would be to limit regulation to commercial rates, as West Virginia has done since the 1980s.

Another challenge is that with broad enthusiasm about the prospects for reformed payment, those contemplating rate setting need to make sure that the mechanism encourages payment reform rather than blocks it. Maryland has been quite careful about this and its recent initiative to broaden its program seems promising. But with the recent emphasis on multi-provider approaches to payment, such as ACOs and bundled payment, the limitation of regulatory authority to hospital rates could be a problem.

So what are my bottom lines for legislative priorities? I have two. States should address restrictions on anti-competitive practices such as anti-tiering restrictions, all-or-none contracting restrictions, and most favored nation clauses. My second is to regulate network adequacy wisely. It is a potent tool for fostering competition, even in consolidated markets. Network strategies do have problems that need to be addressed, but it must be done while preserving much of the potency of the approach.

A concluding thought involves acknowledging that provider payment reform approaches are likely to contribute to consolidation. Small hospitals and medical practices are not well positioned to participate, although virtual approaches can often be used in place of mergers, for example as California’s independent practice associations have enabled many small practices to participate. But I see payment reform as having major potential over time to reduce costs and increase quality. So my advice is to proceed with payment reform but also take steps to foster competition. Rate setting is best seen as a “stick in the closet” to use if market approaches should fail to control costs.


[1] Gaynor, M., and R. Town, The Impact of Hospital Consolidation – Update, Robert Wood Johnson Foundation Synthesis Report (June 2012).

[2] Baker, L. C., M.K Bundorf and D.P. Kessler, “Vertical Integration: Hospital Ownership Of Physician Practices Is Associated With Higher Prices And Spending,” Health Affairs, Vol. 35, No 5 (May 2014).

[3] Chapin White and Megan Egouchi, Reference Pricing: A Small Piece of the Health Care Pricing and Quality Puzzle. National Institute for Health Care Reform, Research Brief No. 18, October 2014.

Downloads

Authors

      




cons

More than price transparency is needed to empower consumers to shop effectively for lower health care costs


As the nation still struggles with high healthcare costs that consume larger and larger portions of patient budgets as well as government coffers, the search for ways to get costs under control continues. Total healthcare spending in the U.S. now represents almost 18 percent of our entire economy. One promising cost-savings approach is called “reference pricing,” where the insurer establishes a price ceiling on selected services (joint replacement, colonoscopy, lab tests, etc.). Often, this price cap is based on the average of the negotiated prices for providers in its network, and anything above the reference price has to be covered by the insured consumer.

A study published in JAMA Internal Medicine by James Robinson and colleagues analyzed grocery store Safeway’s experience with reference pricing for laboratory services such as such as a lipid panel, comprehensive metabolic panel or prostate-specific antigen test. Safeway’s non-union employees were given information on prices at all laboratories through a mobile digital platform and told what Safeway would cover. Patients who chose a lab charging above the payment limit were required to pay the full difference themselves.

Employers see this type of program as a way to incentivize employees to think through the price of services when making healthcare decisions. Employees enjoy savings when they switch to a provider whose negotiated price is below the reference price, whereas if they choose services above it, they are responsible for the additional cost.

Robinson’s results show substantial savings to both Safeway and to its covered employees from reference pricing. Compared to trends in prices paid by insurance enrollees not subject to the caps of reference pricing, costs paid per test went down almost 32 percent, with a total savings over three years of $2.57 million – patients saved $1.05 million in out-of-pocket costs and Safeway saved $1.7 million.

I wrote an accompanying editorial in JAMA Internal Medicine focusing on different types of consumer-driven approaches to obtain lower prices; I argue that approaches that make the job simpler for consumers are likely to be even more successful. There is some work involved for patients to make reference pricing work, and many may have little awareness of price differences across laboratories, especially differences between those in some physicians’ offices, which tend to be more expensive but also more convenient, and in large commercial laboratories. Safeway helped steer their employees with accessible information: they provided employees with a smartphone app to compare lab prices.

But high-deductible plans like Safeway’s that provide extensive price information to consumers often have only limited impact because of the complexity of shopping for each service involved in a course of treatment -- something close to impossible for inpatient care. In addition, high deductibles are typically met for most hospitalizations (which tend to be the very expensive), so those consumers are less incentivized to comparison shop.

Plans that have limited provider networks relieve the consumer of much complexity and steer them towards providers with lower costs. Rather than review extensive price information, the consumer can focus on whether the provider is in the network. Reference pricing is another approach that simplifies—is the price less than the reference price? What was striking about Robinson’s results is that reference pricing for laboratories was employed in a high-deductible plan, showing that the savings achieved—in excess of 30 percent compared to a control—were beyond what the high deductible had accomplished.

While promising, reference pricing cannot be applied to all medical services: it works best for standardized services and where variation in quality is less of a concern. It also can be applied only to services that are “shoppable,” which is only about one-third of privately-insured spending. Even if reference pricing expanded to a number of other medical services, other cost containment approaches, including other network strategies, are needed to successfully contain health spending and lower costs for non-shoppable medical services.


Editor's note: This piece originally appeared in JAMA.

Authors

Publication: JAMA
       




cons

How high are infrastructure costs? Analyzing Interstate construction spending

Although the United States spends over $400 billion per year on infrastructure, there is a consensus that infrastructure investment has been on the decline and with it the quality of U.S. infrastructure. Politicians across the ideological spectrum have responded with calls for increased spending on infrastructure to repair this infrastructure deficit. The issue of infrastructure…

       




cons

The constraints that bind (or don’t): Integrating gender into economic constraints analyses

Introduction Around the world, the lives of women and girls have improved dramatically over the past 50 years. Life expectancy has increased, fertility rates have fallen, two-thirds of countries have reached gender parity in primary education, and women now make up over half of all university graduates (UNESCO 2019). Yet despite this progress, some elements…

       




cons

Gender and growth: The constraints that bind (or don’t)

At a time when 95 percent of Americans, and much of the world, is in lockdown, the often invisible and underappreciated work that women do all the time—at home, caring for children and families, caring for others (women make up three-quarters of health care workers), and in the classroom (women are the majority of teachers)—is…

       




cons

Africa in the News: Zuma violates South African constitution, Angola jails activists and Tanzania suffers aid cuts


South African court rules President Zuma violated the constitution

Thursday, South Africa’s highest court found President Zuma guilty of violating the constitution as he refused to reimburse the large sum of money spent on improvements to his personal home. Between 2010 and 2014, the home located in the president’s rural hometown of Nkandla received improvement which cost an estimated $23 million. The improvements include a chicken coop, an amphitheater, a swimming pool, and a helipad. President Zuma has stated that the improvements were necessary to ensure his security and should consequently be paid for with taxpayers’ money. In 2014, public prosecutor Thuli Madonsela ruled that the president should repay part of the taxpayers’ money spent on the improvements of his personal home. In refusing to do so, he violated the country’s constitution “by not complying with a decision by the public protector, the national watchdog.” The court has given the National Treasury 60 days to determine the sum the president must repay. The opposition has stated that they will seek Zuma’s impeachment.

In other South African news, this week, the rand strengthen against the U.S. dollar and reached its highest value since December 8, 2015, the day before President Zuma fired former Finance Minister Nhlanla Nene. The strengthening of the rand was coupled with the strengthening of other Emerging Markets currencies. This hike follows the statement from Federal Reserve Chair Janey Yellen, reiterating the importance to raise U.S. interest rates cautiously, amid risks in the global economy. Investors—weighting prospects of higher U.S. borrowing costs—were holding off in acquiring emerging-market assets.

Seventeen Angolan activists are sentenced to jail time

This week, 17 Angolan activists were sentenced to jail time for rebellion against the government of Jose Eduardo dos Santos. The sentences ranged from two years to eight and a half years. Last June, the activists were arrested during a book club meeting focusing on Gene Sharp’s book titled From Dictatorship to Democracy: A Conceptual Framework for Liberation—a book on nonviolence and resistance to repressive regimes. Monday, the activists were charged and sentenced with acts of rebellion, planning mass action of civil disobedience, and producing fake passports, among other charges. Amnesty International has accused the Angolan court of wrongfully convicting the activists and using the judicial system to “silence dissenting views.”

Later in the week, in response to the jailing of the young activists, the Portuguese branch of hacking group Anonymous claimed the shutdown of 20 government websites, including that of the Ministry of Education and the Ministry of Labor and Social Security, among others. In a Facebook post claiming the attack, the group states, “The real criminals are outside, defended by the capitalist system that increasingly spreads in the minds of the weak.” The functionality of the websites has been restored.  

Aid cuts due to disputed election rerun hit Tanzania

On Monday, March 28, the U.S. Millennium Challenge Corporation (MCC) withdrew $472 million in aid from the government of Tanzania after the result of the last weekend’s disputed presidential election rerun in the semi-autonomous archipelago of Zanzibar was announced. Incumbent President Ali Mohamed Shein of the ruling Chama Cha Mapinduzi party was declared the winner with 91.4 percent of the vote. However, the rerun was boycotted by the opposition Civic United Front party over the cancellation of last October’s election by the Zanzibar Electoral Commission. The commission claimed the October poll was fraudulent, while the opposition says the allegations of fraud were fabricated to thwart a victory by their candidate.

The MCC was planning a number of power and infrastructure projects in Tanzania, but its development assistance programming is conditional upon beneficiaries meeting certain standards of good governance. The MCC’s board of directors held a vote on Monday, in which they determined that Tanzania was no longer eligible to partner with the MCC given the election outcome. Although the loss of the MCC partnership is a sizable blow to the Tanzanian government, the Tanzanian finance minister appeared optimistic that the power projects would continue despite the MCC’s decision, as he stated: “We weren’t surprised at all because we were prepared for whatever the outcome. We will implement those projects using local sources of fund and the support of from other development partners.” Meanwhile, 10 out of the country’s 14 key western donors withdrew general budget support to Tanzania over the contested election.

Authors

  • Mariama Sow
      
 
 




cons

Coronavirus is also a threat to democratic constitutions

It has become a truism to assert that the pandemic highlights the enduring importance of the nation-state. What is less clear, but as important, is what it does to nation-states’ operating systems: their constitutions. Constitutions provide the legal principles for the governance of states, and their relationships with civil society. They are the rule books…

       




cons

The constraints that bind (or don’t): Integrating gender into economic constraints analyses

Introduction Around the world, the lives of women and girls have improved dramatically over the past 50 years. Life expectancy has increased, fertility rates have fallen, two-thirds of countries have reached gender parity in primary education, and women now make up over half of all university graduates (UNESCO 2019). Yet despite this progress, some elements…

       




cons

Gender and growth: The constraints that bind (or don’t)

At a time when 95 percent of Americans, and much of the world, is in lockdown, the often invisible and underappreciated work that women do all the time—at home, caring for children and families, caring for others (women make up three-quarters of health care workers), and in the classroom (women are the majority of teachers)—is…

       




cons

Coronavirus is also a threat to democratic constitutions

It has become a truism to assert that the pandemic highlights the enduring importance of the nation-state. What is less clear, but as important, is what it does to nation-states’ operating systems: their constitutions. Constitutions provide the legal principles for the governance of states, and their relationships with civil society. They are the rule books…

       




cons

Redistricting and the United States Constitution


Thomas Mann joins Sean O’Brien and Nate Persily on the Diane Rehm Show to examine what the U.S. Constitution says about drawing congressional and legislative districts and how court decisions have further shaped those guidelines.

DIANE REHM: Thanks for joining, us I'm Diane Rehm. The framers of the U.S. Constitution did not use the word district when they outlined how Congressional representatives would be chosen. Article 1, Section 2 of the document states only how to choose the number of lawmakers. Today, the redistricting process has become at times contentious and blatantly partisan. As part of our "Constitution Today" series, we look at what the document says about the process of redistricting and how court cases have furthered shaped those guidelines.

Joining me here in the studio are Sean O'Brien of the Center for the Constitution at James Madison's Montpelier, Thomas Mann of the Brookings Institution and joining us from Columbia Law School where he is The Beekman Professor of Law and Political Science, is Nate Persily. Throughout the hour, we'll welcome your calls, questions, 800-433-8850. Send us your e-mail to drshow@wamu.org. Good morning, gentlemen. Thank you for joining me.

SEAN O'BRIEN: Good morning.

THOMAS MANN: Good morning.

NATE PERSILY: Good morning.

REHM: Sean O'Brien, let me start with you. What does the constitution actually say about legislative districts and I'm glad that you have a copy of the constitution right in front of you, good. Nate Persily has his as well.

O'BRIEN: As you indicated in the opening it's very, very vague, as are many things in the constitution, and we have to figure out how to implement what this constitution says. Really what they did initially was set up the initial representation and came up with the number of representatives that each state would have before they knew how many people lived there and set up a minimum number of representatives that each state could have and the maximum size, which they could be.

And so they basically -- it just says here the actual enumeration shall be made within three years after the first meeting of the Congress of the United States and within every subsequent term of 10 years, in a manner as they shall by law direct. The number of representatives shall not exceed one for every 30,000, but each state shall have at least one representative. And until such enumeration shall be made and then they lay out which states get how many members of Congress in the first Congress.

And that gets into an interesting story that Tom and I were talking about out in the lobby, but again, it's pretty open and that's why we have a lot of opportunities to continue to talk about this issue right now.

REHM: All right. And turning to you, Nate Persily, when did the word district first come into play?

PERSILY: Well, for hundreds of years now, we've had districts, but as Sean said, there's no constitutional requirement that we have it. We have since the Supreme Court decisions in the 1960s abided by a rule of population equality for congressional and other districts and are drawn but Congress then has passed statutes, various apportionment statutes over time that have required single member districts and the one that currently exists today is about 90 years old.

REHM: Ninety years old? Tom Mann.

MANN: It's important to remember the other provision of the constitution that is relevant here is Article 1, Section 4, the times, places and manner of holding elections for senators and representatives shall be prescribed in each state by the legislature thereof. So it was the states that were given the authority to decide how those representatives would be elected. They could have set up a proportional representation system, everyone running at large statewide in which case redistricting would never have arisen as a problem.

Listen to the interview or read the full transcript at thedianerehmshow.org »

Authors

Publication: The Diane Rehm Show
Image Source: © Jonathan Ernst / Reuters
      
 
 




cons

Drafting Egypt’s New Constitution


With parliamentary elections now complete, Egypt moves to the next major step in its fitful political transition -- drafting a new constitution for the republic. As the fundamental document establishing a framework for governance, the new Egyptian constitution will have a lasting effect on Egyptian law, politics, and society.  However, Egypt’s transition is shaping up to be a case study in how not to initiate a constitution-writing process.

At a time when the shortcomings of a mismanaged transition threaten to undermine the constitution-writing process, author Tamir Moustafa identifies the most important issues to be tackled by the country’s Constituent Assembly. Focusing on questions that range from the place of Islamic law to women’s rights to the role of the military, he offers recommendations on how each area should be addressed.

The paper – the first to be published under the new Brookings Doha Center-Stanford Project on Arab Transitions – concludes that while constitution writing must be treated as an organic process, the international community should work to ensure that Egypt’s military does not entrench a role for itself in domestic governance.

Downloads

Authors

  • Tamir Moustafa
Publication: Brookings Doha Center
Image Source: © Amr Dalsh / Reuters
      
 
 




cons

Consensus plans emerge to tackle long-term care costs

There has been a determined and serious effort in recent years by a broad range of organizations and analysts to find a consensus approach to the growing problem of financing long-term care in the United States. These efforts have just resulted in 2 major reports, released in February.

      
 
 




cons

Fostering competition in consolidated markets

On March 16, Paul B. Ginsburg testified before the California Senate Committee on Health on fostering competition in consolidated markets.

      
 
 




cons

What China’s food safety challenges mean for consumers, regulators, and the global economy

China’s food safety woes are well-known. Addressing food safety concerns can be seen part and parcel of China’s needed transition toward a consumer-oriented economy, which is even more imperative now that the country’s GDP growth is slowing from historic rates. Boosting consumer confidence is an essential piece of that puzzle for China—and by extension, a factor for global economic stability.

      
 
 




cons

Turkey’s failed coup could have disastrous consequences for Europe’s migrant crisis


Editors’ Note: Turkey’s failed coup may lead to the worsening of Europe’s migration crisis, writes Jessica Brandt. That’s because it could lead to the dissolution of a recent pact between Brussels and Ankara over the plight of refugees arriving on the European Union’s shores. This post originally appeared on Vox.

Turkey’s recent failed coup may lead to the worsening of Europe’s migration crisis. That’s because it could lead to the dissolution of a recent pact between Brussels and Ankara over the plight of refugees arriving on the European Union’s shores. Even before the events of last weekend, the fate of the agreement was uncertain amid quarrels between the parties. Now its future is even more in doubt.

Last year, more than a million migrants and refugees crossed into Europe, roiling politics across the continent. It’s a crisis EU chief Donald Tusk has described as an “existential challenge.”

Under the terms of the deal, Turkey agreed to accept the “rapid return of all migrants not in need of international protection crossing from Turkey into Greece and to take back all irregular migrants intercepted in Turkish waters.” In other words, almost all refugees who cross into Greece are slated to be returned to Turkish soil.

In return, the EU pledged to speed up the allocation of €3 billion in aid to Turkey to help it house and care for refugees, “reenergize” Turkey's bid for membership in the EU, and lift visa restrictions on Turkish tourists and businessmen.

But the European Commission has conditioned changes to the visa restrictions on better governance in Turkey. In particular, it requires a change in President Recep Tayyip Erdoğan’s controversial anti-terror law, which he has used to crack down on journalists and critics. Erdoğan was already adamantly against narrowing the law to protect free speech. Having now overcome a determined coup attempt, he is even less likely to do so.

Instead, it appears probable that he will further clamp down on civil liberties, acting on his authoritarian instincts and retaliating against his detractors. On Sunday, he suggested that he might reintroduce the death penalty, a practice Turkey abolished in 2004 as part of its bid for EU membership. Doing so would widen the gap in political culture between Turkey and Europe and, as German Foreign Minister Frank-Walter Steinmeier asserted forcefully on Monday in Brussels, derail the already limited possibility of reigniting accession talks.

The pact has already been strongly opposed by the European left, and particularly by humanitarian and human rights groups. Rising authoritarianism in Turkey would only increase resistance to the deal, making implementation even harder, especially if those groups were to scale back their activities on the ground.

That would not be without precedent. The United Nations High Commissioner for Refugees, Doctors Without Borders, and the International Rescue Committee, among others, have suspended some of their activities in refugee centers because they do not want to be involved in implementing a deal that they describe as constituting the blanket expulsion of refugees from Turkey back to Greece.

[A] crackdown could also undermine the legal basis of the agreement.

Crucially, a crackdown could also undermine the legal basis of the agreement. One of the agreement’s key provisions is that individuals who cross from Turkey into Greece will be sent back across the Aegean to Turkey. That hinges on the notion that Turkey is a “safe third country” for migrants. A crackdown could prompt refugees to argue that it isn’t.

If that were the case, deporting them to Turkey could be seen as constituting “refoulement”—the forcible return of asylum seekers to a country where they are prone to be subjected to persecution—which is forbidden under both international and EU law.

That’s a problem, since some analysts believe worsening conditions in Turkey could lead even more people seeking refuge to journey onward to Europe. In the past, Erdoğan has threatened to “open the gates” and send refugees streaming into Europe when displeased with the level of financial assistance from Brussels earmarked for managing the crisis. Preoccupied by troubles at home, he may see stability as in his interest and resist taking aggressive steps that would cause an open breach.

For both parties, finding a stable, though imperfect, accommodation—as they were poised to do prior to the events of last weekend—is still the most promising path forward. Let’s hope the parties take it. Managing Europe’s migration crisis depends on it.

Authors

Publication: Vox